A Woman Dies While in the Care of Salt Lake County Jail Staff

KUTV, SALT LAKE CITY — A difficult-to-watch 2News investigation reveals how a woman’s stop for a broken taillight resulted in her being given the death penalty. Wendy Halloran, the chief investigative reporter, spent months going over documents and watching videos to learn how Breanna Jimenez passed away while being held at the Salt Lake County Jail and why it took so long for nurses and deputies to call for aid.

She Died Face Down Alone in a Padded Cell at the Salt Lake County Jail

Since 2018, 27 prisoners have passed away while being cared for and supervised by correctional officials in the Salt Lake County Metro jail. One of them is Breanna Jimenez, who is 25. A 2News investigation revealed that jail personnel failed to notice Jimenez ingesting a baggie of methamphetamine, responded slowly to her drug overdose, made notes indicating they believed she was lying, told a nurse she saw something blue in her mouth and swallowed it, initially suspected she was on amphetamines, placed her in a cell with another inmate who banged on the glass for help, banged her leg into a wall, then forcibly placed it back on.

Jimenez’s mother Brandy Tibbetts sued Salt Lake County on grounds of negligence, wrongful death, and violation of her constitutional right to receive treatment for a serious life-threatening medical emergency.

She also claimed that the county’s employees and administrators had a “callous indifference toward human life” and that this was in violation of her constitutional rights.
Lieutenant Cole Warnick of the Salt Lake County Sheriff’s Office stated in an email that no comments could be made because of the ongoing litigation. Sheriff Rosie Rivera was prohibited from agreeing to our request for an interview about this situation on camera.

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The Traffic Stop

On June 17, 2019, near 650 South 300 West, Utah Highway Patrol Trooper Nick Hansen pulled Breanna Jimenez down for a broken taillight. The left stop lamp wasn’t working when she came to a stop at the intersection, according to Trooper Hansen’s report. She admitted to him that her automobile was uninsured and that she had just retrieved it from a tow yard because it was at the time uninsured.

In his patrol car, Trooper Hansen searched and discovered numerous warrants. She was driving with a suspended license, which he discovered while checking to see if she had insurance. She was questioned about why she had so many outstanding warrants for driving while suspended.

The chat he had with another UHP employee while debating whether to arrest her and impound the automobile is captured on body camera footage. In the end, Trooper Hansen declared that he would be the bad guy today and that it would be best to serve her with warrants and impound her car for driving without insurance. Jimenez started to sob hysterically as she begged Trooper Hansen to give her a respite.

Breanna Jimenez: I swear I won’t drive if you put the keys under my seat. Do not do it; it will not benefit me. Please, I urge you, to take the automobile. I’m trying to make changes in my life. Please, Hansen, please, please, please I ask you, please refrain from doing this; I’ll do whatever to improve my life. She was placed under custody, and the dispatcher reported that no female cops were available to assist with the search.

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The video demonstrates him checking her back pockets with the back of his hand. She said “No” when he questioned whether she had anything illicit in her bra or jeans. Then he can be heard warning her that if anything was discovered in the jail, the charge would be increased.

He and Trooper Bender discovered a yellow baggie containing five round orange pills with a superman emblem and a red straw with one burnt end as they began to inventory her vehicle. At that point, a female police officer from Salt Lake City arrived to help with the search for Jimenez. She admitted to having a glass pipe in her bra and saying the orange tablets were for motion sickness to Salt Lake City police officer LeGore.

Due to Jimenez’s lack of insurance, driving while his license was suspended, possession of drugs and drug paraphernalia, and outstanding warrants, Trooper Hansen took him to the Salt Lake County Jail. Although it is indicated on the papers, the jail booking sheet conceals whether Trooper Hansen informed jail employees about what they found.

Utah Highway Patrol Sergeant Cameron Roden, the public information officer, was contacted by 2News Investigates to provide additional details regarding the arrest.
He claimed that because Trooper Hansen’s body camera was not recording inside the jail and it had been a while since the incident, he could not recollect, they had no way of knowing if he had informed the jail personnel that they had discovered drugs on Jimenez.
According to Sgt. Roden, “We were unable to confirm if the trooper personally talked to jail staff to inform them about the possibility of drugs.”

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Walking, Talking as She is Led Into Intake

When Breanna Jimenez arrived at the jail, she was shackled to the bar on the “Intake Bench” with other people who had been detained that evening while they awaited to go through the booking procedure.
Her repeated attempts to retrieve something with her lips along her bra strap can be seen on surveillance footage. Despite being shackled to the bar, she is moving around and fidgeting. Nobody appeared to have noticed.
It’s thought that she swallowed a blue balloon containing methamphetamine at this time, however, it wasn’t immediately obvious if she was able to do so.

Deputy Spots Something Blue in Her Mouth

Deputy Andrea Barnett noticed a blue item in her mouth when she was being booked. She was searching for her together with Deputy Jesse Fitzgerald. The sheriff’s report states that when Deputy Barnett questioned Breanna about it, she reportedly swallowed the blue object. Deputy Barnett inspected her mouth once more and discovered that it was gone.

A little while later, Jimenez and another prisoner were transferred from the booking to the holding cell. According to another allegation, Deputy Barnett informed the intake nurse of what she had seen. Intake nurse Julie Mahlstede completed the medical papers at 9:16 p.m. to confirm that she was okay to be admitted to the jail and noted that the search deputy had said that she might have ingested anything.

HOLDING CELL 3 “H3” SHOWS FRUSTRATED ACTION

According to a jail surveillance video, the nursing personnel examined Breanna at about 8:46 p.m. She’s observed pacing the cell and splashing water in her face. Her vital signs were examined by the nursing team, who determined that she was having a panic attack. David Sperry, the Jail Watch Commander, encountered Breanna less than 45 minutes later and saw that her shirt was soaked.

She used splashing water as a “coping method” for her nervousness, the nursing staff informed him after he inquired. Angela Biesinger, who shared a cell with her, then began pounding on the window to warn the jail personnel that something was seriously wrong.

The report states that Biesinger informed Deputy Boyd that Breanna had ingested narcotics. According to records, he informed the nursing personnel who then informed him that she was suffering from a panic attack. Breanna was lying on the cell floor at this time. According to an interview with Deputy Boyd, he returned to Breanna’s cell at roughly 10:10 p.m. and attempted to encourage her to stand up but was unable.

She did not react to the ammonia pill that he had obtained. A deputy shoved her feet while she was still on the ground so he could close the cell door. The report also reveals that Deputy Boyd told the healthcare personnel that she was unfazed by having an ammonia capsule inserted under her nose. According to the interview transcript, he approached the nurses and instructed them to check on the patient.

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The hospital personnel allegedly informed Deputy Boyd that she was refusing the smelling salts by holding her breath, according to the investigation. Records also show that Deputy Boyd escalated his concerns to the nursing staff who were on duty that night, Julie Mahlstede, Joel Smith, and Karen Pineda.

He then revealed to a South Salt Lake Police Department investigator that he had been instructed not to be concerned because she had just been examined and was fine.
Breanna was described as “pretending” by the nursing staff, according to one of his supervisors.

Boyd also mentioned during the interview that when he first saw Breanna, her eyes were open and she was coherent. In the following fifteen to twenty minutes, he continued, “she was sluggish with her eyes closed.”

Moved to Padded Cell

After that, Breanna was placed in a “Staxi chair” and taken to a padded cell.
Breanna was not responsive, unable to move, floppy, and unable to sit in the chair, and it appeared as though she was about to fall out of the transport chair, according to the security footage and handheld video captured by a deputy that documented this transport.

as she enters on a wheel Deputy Alexander Bosley appears to knock her leg against the wall by accident as he tries to enter the room. He pulls the chair back and is then seen grabbing her leg and shoving it down firmly on the foot pedal.

Jimenez is placed on his back. Deputy Bosley, who moved the chair to cell P3, noted in his report, “I assisted in lifting Jimenez from the chair and assisting in laying her on the ground. Her head was twisted to the side as we lay her face down. That idea is disproven by the video. None of them moved or turned her head to the side at any point in the video.

Prone

In this instance, we hired independent expert Melissa Becker, a Minneapolis-based certified forensic nurse, and legal nurse consultant. In addition to working on several cases for the public defender’s office, Becker has provided medical advice in hundreds of civil medical malpractice proceedings. She focuses on reviewing the standards of care in criminal and civil investigations.

Sheila Halloran What did you think when you saw that? Wow, Melissa Becker exclaimed. No nurse in their right mind would have allowed a patient to lie in that position under any circumstances. She is on her back. She’s a little, little overweight, so when you’re lying prone and face down that hinders your capacity to breathe as well.

When someone is lying face down with respiratory suppression, which occurs as a result of a narcotic overdose, you are merely rebreathing CO2 since their face is in the ground, which furthers the physical obstruction of their lungs from breathing. I’m not sure how you manage to accomplish that and maintain your nursing license. It disgusts me so much.

THE FINGER PRICK

Eight minutes later, two deputies and nurse Joel Smith entered the padded cell. Since Nurse Smith has diabetes, it appears that she performs a finger stick blood sample to monitor her blood sugar level. The footage demonstrates that she did not respond when her finger was poked. They can see her twitching on the ground in the footage.

When he’s finished, they leave and close the door. Becker is quite worried about that.
She asked, “How do you walk out the door with a purple finger and do nothing with good conscience?” She continued, “Her wrists and arm were purple, as were her fingers and foot.” For 28 to 29 minutes, Jimenez was left in the prone position. “You’ve now seen her laying prone; you do nothing,” Becker says.

JIMENEZ STOPS MOVING

Surveillance footage reveals Breanna Jimenez stopped moving at 10:33 p.m. The video also reveals that after Nurse Smith and the two deputies left, it took 16 minutes before anyone returned to see how she was doing in the padded cage. Breanna remained motionless for 14 of the 16 minutes, as seen in the video.

At 10:30:47 approximately Breanna was visited by Sergeant Emelie Sundwall. She knelt down while focusing on her and put on some gloves to check her pulse. When she was unable to locate one, she made a nurse staff call. At 10:49 p.m., Julie Mahlstede and Joel Smith, the nurses who pierced her finger, entered the padded cage and turned her over. Her face is definitely quite purple and swollen in the video.

“She turns purple when they roll her over. She’s purple,” said Becker angrily. “You can see on the video that her extremities are purple; this means that the extremities aren’t receiving blood perfusion. She is purple. She has been dying for well over an hour after entering that padded chamber, which is why her face is swollen and purple.

“What happens is that narcotics suppress the brain and the respiratory system, and when the drug level is high enough, the combination of the respiratory suppression and the heart arrhythmias, the abnormal heart rhythms combine together and the person slowly, slowly, slowly stops breathing,” she continued.

Because of this, you can notice purple on the tips of the fingers and toes before it goes up to the wrist. It is shown in the video. Following that, it advances to the open, complete right arm. When they roll her over, you can see purple all the way around. She is violet.
Along with that, according to Becker, “You only turn purple because you’ve been facing down on a cement slab and you’re unconscious so you can’t move.”

Additionally, according to Becker, “We witnessed a movement that was twitching, twitching from a narcotic overdose. Everything they recorded was the result of a drug overdose, thus the jail nurses shouldn’t be working there if they don’t know what one looks like.

The padded cell is abruptly abandoned by Nurse Smith, who returns later with assistance and supplies. When nurse Karen Pineda arrives, they start performing CPR. It’s too late, though. The call for paramedics comes in around 10:52. Seven minutes later, they arrived at the jail and took over CPR.

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“A PREVENTABLE DEATH”

“What’s fascinating is that methamphetamine has a peak blood plasma level at around two to two and a half hours, she dies at two and a half hours when it gets the peak level,” Melissa Becker said after reading the medical examiner’s report. You can now address that as the medicine has been absorbing for two to two and a half hours.

“They could have taken her to the emergency room, given her activated charcoal to absorb whatever was still in her stomach, monitored her, made sure she was breathing, had oxygen, blood pressure support, IV fluids, all of these things, and when she started to decline, even more, they could have given her an infusion of Narcan to keep her awake,” she continued.

There was just so much that could have been done, and once more, nursing failed. “This was a preventable death for two and a half hours,” claims Becker. Furthermore, she adds, “This is not how it would have been treated if this patient had presented to the emergency room. So why are they handling it any differently at the jail’s intake area when it serves as the equivalent of the emergency room?

And because you are locked up and unable to advocate for yourself, the jail personnel, including the nursing staff, has accepted the responsibility to do so when you are booked into jail.

You cannot call an ambulance for yourself or transport yourself to the emergency room. Because they assumed that obligation from her and afterward refused to provide her with basic human care, it is all the more outrageous.

INITIAL PAPERWORK REVEALS NURSES THOUGHT SHE WAS ON AMPHETAMINES

The original paperwork reads, “Patient denies eating anything or using any substances today. The search deputy indicated that it appeared like the inmate may have swallowed anything during the search. I’ll keep checking for intox in the holding cell to monitor. Regarding what they recorded, Becker had the following to say: ‘Monitor what?

Okay, her breathing is becoming increasingly erratic; she is now dead, and she is still dying. I kept track of everything that occurred, but I took no action. Nurse Julie Mahlstede checked off “Signs of acute intoxication present” in her notes at 9:16 p.m.

The nurse noted, “says is simply having a “panic attack” and appears to be under the effect of amphetamines/stimulant,” under details on substance use: last used, method, amount, etc. According to your assessment, you believe they are amphetamine-impaired, and you have been informed that they consumed something, Becker stated.

Why did this not occur to them, oh my god, we need to act. She enters the room walking, chatting, and alert-oriented four times, person, place, time, and circumstance, and over the course of two and a half hours, she slowly deteriorates. You were aware that she was impaired, she ingested something, and her health worsened over time, but you did nothing to rule out the most serious condition, a drug overdose, which is treatable.

According to Breanna’s mother, Brandy Tibbetts, “If it was any of their daughters and they were working, they would have done something. My daughter would still be here today if they would have treated her that way.” They ought to have dialed 911 right away and should never have permitted her to experience what she did.

NURSE JOEL SMITH DOCUMENTED BREANNA’S VITAL SIGNS AFTER SHE WAS DEAD

One initial set of vital signs was recorded by the nursing staff, according to jail staff medical records obtained by 2News Investigates. Our inquiry revealed that even after she passed away, Nurse Joel Smith continued to record her vital signs the following day. There is no mention of a time on his nursing note, which is dated June 17, 2019.

It also doesn’t say if it was submitted late. There is a requirement, according to Becker, to avoid giving the impression that it deviates from the nursing standards of care. According to the audit trail, Smith opened a nursing note the following day, on 6/18/2019 at 7:17:59 a.m. However, the date was typewritten as June 17, 2019.

The form expressly states: NO ANSWER PROVIDED and asks for Time. Jimenez was formally pronounced dead by paramedics at 11:31 p.m. on June 17th, according to the Medical Examiner’s report. After the initial note, which was opened once more at 7:17:59 a.m. on 6/18/2019, that note was amended twice.

It displays two modifications, the first at 02:58:44 and the second at 5:17:59. Furthermore, there is no indication in the nursing note that it is a late entrance. A nurse can submit late entries, but they must be marked as such, according to Becker. In order to give the appearance that the date was written when events were happening and being logged by precise times, Nurse Smith wrote the date as 6/17/2019.

The changes are made following the autopsy, which was performed on June 18 at 8:10 a.m. According to Becker, “How did you know what the blood pressure was the next day, the pulse, and the respirations you didn’t know if you didn’t have those vital signs written down somewhere?

A late entry usually conveys the attempt to justify oneself from anything they are aware they have done wrong. It is so terrible, she claims, that the County Attorney should investigate whether any laws were broken and file charges against the nurses.

NURSE KAREN PINEDA SENT HOME BY JAIL ADMINISTRATORS

The Salt Lake County jail managers sent Nurse Karen Pineda home, according to the investigation report from South Salt Lake Police Detective Joe Sutera who was tasked with looking into this death while in custody. According to his report, “Administrators at the Salt Lake County Jail sent Nurse Karen Pineda home because she was also involved in this event. Det. Sutera mentioned that he would like to speak with Karen, the nurse, therefore I will schedule the interview for a different time.

Lt. Cole Warnick was questioned by 2News Investigates about Pineda’s reassignment. He informed us that would be covered by the inquiry and litigation, thus he was unable to respond. The investigative report also noted: “I got in touch with Karen Pineda. She agreed to an interview when I urged her to come in.

She declared that she wanted to speak with a lawyer. I informed her that was her right and requested that she call me following her consultation to let me know if she would be coming in. According to his report, he spoke with nurses Joel Smith and Julie Mahlstede, who both claimed that the search deputy had informed them that Breanna might have ingested something.

No record can be found indicating that Karen Pineda was ever questioned as part of this investigation. Here is what we learned after asking Lt. Warnick about the employment status of people engaged in this crucial incident. Less than three months after Breanna’s passing, two of the nurses departed from the Salt Lake County Sheriff’s Office. Warnick would not specify if they had been fired or had quit on their own.

2NEWS INVESTIGATES REACHED OUT TO NURSES JULIE MAHLSTEDE, JOEL SMITH, AND KAREN PINEDA

To hear the nurses’ side of the story regarding Breanna Jimenez’s treatment that evening at the Salt Lake County Jail, 2News Investigates made an effort to talk with them. In the complaint, all three are named defendants. All three were reached by phone and email, but none of them responded. All three of them are currently licensed as nurses in the state of Utah.

Further inquiries were made regarding the employment status of the following individuals, who were listed on the investigative reports and Salt Lake County Sheriff’s Office report: Richard Bell, Kevin Harris, Sgt. Emelie Sundwall, Deputy Andrea Barnett, Deputy Jesse Fitzgerald, Alexander Bosley, Deputy Boyd, Skyler Anderson, Byron Hicks, Lt. David Sperry, Sergeant Jacobson, Stephanie Clarin, Sarah Underwood, Pete Stokes, Spencer Lopez, Valerie Ziemski,

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